Coronavirus impacts in rural America (Part I: Health)

The media are increasingly paying attention to how coronavirus is playing out differently in rural and urban areas.  From the perspective of a ruralist, the news is mixed.  First, commentators seemed to suggest that rural America would fare better than the rest of the nation because it is less exposed--less in contact with the people who would have the virus.  An illustration of this is that as of March 16, West Virginia didn't yet have a single positive test.  Other states popularly thought of as "rural" were slow (compared to other states) to identify their first cases; these include North Dakota, Arkansas, Idaho, Mississippi, Alabama, New Mexico, Wyoming and Maine, none of which had a single diagnosed case as of March 10).  Of course, we don't know whether this is because people there did not have access to testing or whether, in fact, the virus was slow to spread there.

This Washington Post story from today indicates that population density drives the spread of the virus, which helps explain why many rural areas are not as hard hit.  An exception to that "rule" of low incidence in rural communities is here, from the New York Times, out of Cynthiana, Kentucky, population 6,402, where six cases were diagnosed the first week in March.

The media have also shifted some of their coverage to rural deficits, particularly in the health care sector, which will make it difficult for rural hospitals and medical professionals to deliver the standard of care associated with more populous places. 

An example of this is NPR's March 15 story out of Grangeville, Idaho, population 3,141 and the county seat of Idaho County, the largest in land area in the state and spanning the width of Idaho, from Montana to Washington State, just as the state's territory narrows to the panhandle.  Here's an except from the story by Kirk Siegler, a veteran reporter on the American West: 

Syringa Hospital has just 15 beds, an emergency room and a clinic. As is common in rural medicine, the chief medical officer, Dr. Matthew Told, is also a family practice OB and, on a recent evening, the on-call ER doc. 

"We don't have ventilator services, we don't have respiratory therapy," Told says during a break between seeing patients. 

There is no intensive care unit. So when they do get a critically ill patient or trauma victims, it's standard protocol to stabilize and transfer them to a large regional hospital in western Montana or Spokane, Wash. But what if ICUs in those places become overwhelmed with coronavirus patients? 

"The biggest challenge is living so close to a state where there are so many cases, such as Washington, and having that really just across the border," Told says. 

And a few paragraphs later is this related, illuminating comment from Dr. Mark Deutchman, associate dean for rural health at the University of Colorado's medical school.

If the places that you rely on to send your critically ill patients are full, then you're stuck.

In other words, this Grangeville hospital and is at the mercy of larger hospitals in Washington State, or perhaps in Montana or in Lewiston, more than an hour to the north, if a patient needs a ventilator.  Rural hospitals face other challenges:

Told knows that his hospital could soon be completely overwhelmed and unable to effectively treat anyone, coronavirus patient or not. This is the story in many communities right now. But it could have an even more dire effect in isolated rural towns like this that lack the infrastructure or trained staff, especially if they were to get sick and couldn't come to work.

A similar story is reported from nearby Dayton, Washington, population 2,526, by Eli Saslow of the Washington Post.  The themes are the same:  under-resourced facility with few staff, reliant on larger hospitals in the region, in this case Walla Walla and Spokane, if the need arises.  Here's an atmospheric quote from the story, which provides context for both Dayton General and what is happening to rural hospitals across the United States:

[Dayton General] had ... for the past several years [been] somehow keeping the doors open even as America’s rural health-care system collapsed all around them, with 125 other rural hospitals around the country closing for budget reasons and doctor shortages spreading across 85 percent of rural counties. Dayton General could no longer afford to offer obstetrics, endoscopy or surgery of any kind. Its emergency room and nursing home were both losing more than $1 million per year. But the hospital remained the final lifeline for an aging community of about 5,000 people in a rugged corner of southeast Washington state, isolated from all other medical care by 35 miles of barley and wheat.

Noting that Dayton General has not ventilators, Saslow continues:

“This is a virus that can take over and expose your weaknesses,” [Shane] McGuire [CEO of Dayton General] said, and he feared that was true for both rural residents and the beleaguered hospitals left to care for them.

The virus had just arrived in rural America, but already, small hospitals across the country had begun bumping up against the limitations of their resources. A facility in the Berkshires had lost much of its nursing staff to a 14-day quarantine. A critical access hospital in North Texas had only one face shield in storage and couldn’t acquire any others. A hospital in Wisconsin was borrowing sterilized medical gowns from local dentists.

As is typical of Saslow's reporting, the story features lots of great human interest angles, including an aging physician who retired to his hometown a few miles from Dayton, only to become the emergency department director at Dayton General a few years later.

As I write this, I'm listening to Governor Gavin Newsom's long press conference for this afternoon, and he's talking about the President's embrace--finally--of telehealth use by Medicare.  As many rural folks already know, telehealth can be a lifeline--literally.

Here's a much earlier story (relatively speaking in this time when a month seems to pass every few hours), from March 5, by the Center for American Progress.  This excerpt highlights rural demographics and economics--as well as rural deficits--and their salience to the coronavirus outbreak:

The CDC also urges people to contact their health care professional if they believe they may have been exposed to the virus. 

For many vulnerable individuals, following these instructions are not an option. Though government health agencies may instruct the public on how to combat COVID-19, they don’t give them the capacity or tools to do it. For rural America, which has a higher proportion of people vulnerable to the virus—including those who are older and those with disabilities—these resources are sorely lacking. 

As experts have recently noted, many low-income individuals are employed in occupations that do not have health benefits or provide paid sick leave. Rural workers are less likely to have access to paid sick leave than urban workers. Many individuals may be working several jobs so, for them, staying home is not financially feasible. Some companies have encouraged their employees to work from home in order to reduce the chance of transmission, but that isn’t feasible for individuals that don’t have reliable, high-speed internet access at home. Many more Americans work jobs that cannot be performed remotely. 

For many who live in rural areas, including many communities of color, LGBTQ people, and people with disabilities, these factors make it impossible to work remotely. Almost one-third of rural households lack internet at home. Though many conflate the agriculture sector with the entire rural economy, the service sector employs the largest number of workers in rural counties, and many of those are in lower-paid occupations in the education, health, and food service sectors. More likely than not, these workers cannot work remotely—nor can they afford to miss work. Because of the economy that rural Americans face, they do not have the capacity to keep themselves safe from COVID-19 and continue to make a living. 

This story, by Olugbenga Ajilore, a senior economist for the Economic Policy Team at the Center for American Progress, and Zoe Willingham, a research associate for the Economic Policy Team at the Center, is chock full of helpful links providing detailed rural context re economics and demography.

P.S.  Another resource I just discovered on March 18.

P.P.S.  These projections from March 20 suggest that some rural areas--see north central Montana--will not be hard hit even under the worst-case scenarios associated with no social distancing.  Generally, more sparsely populous areas will be less hard hit--just look at places like California's Inland Empire, West Texas, western parts of Nebraska and Kansas, and the corner of the remote Arkansas Ozarks where I grew up.